OECD Health Policy Studies
Realising the Potential
of Primary Health Care
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Please cite this publication as:
OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/a92adee4-en.
ISBN 978-92-64-93333-0 (print) ISBN 978-92-64-56162-5 (pdf)
OECD Health Policy Studies ISSN 2074-3181 (print) ISSN 2074-319X (online)
Photo credits: Cover © Photographee.eu/Shutterstock.com.
Foreword
Even before the COVID-19 pandemic, health systems in OECD countries faced significant challenges. Citizen expectations about health services are high, societies are ageing, health spending is rising in response to more complex health needs, and fiscal pressures make it difficult to expand allocations of resources to the health sector. The rapid spread of COVID-19 added complexity to these challenges, given both the surge in demand for treatment of the acutely ill and the need to continue to deliver preventive care and manage chronic patients. In this context, primary health care plays a key role for health systems to deliver more and better services. As the first point of contact that is expected to address the majority of health needs, strong primary health care has all the potential to improve health outcomes for people across socio-economic levels and to reduce unnecessary use of more expensive specialised services. But is primary health care across the OECD ready and living up to these expectations?
Realising the Potential of Primary Health Care discusses how primary health care across OECD countries
needs to evolve to meet the health challenges that OECD health care systems – and societies more broadly – are facing in the 21st century. It identifies key policy ingredients that countries need to implement to realise the full potential of primary health care. Even in the aftermath of the COVID-19 pandemic, these remain as important as ever, as primary health care is expected to continue to address the majority of health needs. Based on data collected before the COVID-19 pandemic, the report uses a mix of quantitative and qualitative analyses, including information collected through a policy survey covering 26 countries, to suggest key policies and strategies to deliver better primary health care and create stronger primary health care systems. It highlights examples of useful -often local- country experiences.
Realising the Potential of Primary Health Care stresses that there are far too many countries with
unrealised opportunities from better primary health care. High-quality primary health care is not always delivered, with avoidable hospital admissions still representing 6% of hospital bed-days across 30 OECD countries for which data are available. Estimates of inappropriate antibiotic prescriptions in primary care range from 45% and 90%. One-quarter of patients suffering from chronic conditions in EU countries did not receive any preventive tests in the past 12 months. Between 29% and 51% of people in 11 OECD countries reported having experienced problems of co-ordination between primary care and specialised care.
improved ability to access – and interact with – their own records, especially key for those living for many years with chronic conditions.
Countries will certainly conduct thorough reviews of the provision of health care as they seek to draw lessons from the COVID-19 pandemic. Modernising primary health care services is critical to make health systems more resilient to situations of crisis, more proactive in detecting early signs of epidemics and more prepared to act early in response to surges in demand for services.
Acknowledgements
The preparation and writing of this report was co-ordinated by Caroline Berchet and Frederico Guanais. Chapter 1 was written by Caroline Berchet and Frederico Guanais, Chapter 2 by Caroline Berchet, Cristian Herrera and Frederico Guanais, Chapter 3 by Caroline Berchet, Dionne Kringos (Academic Medical Centre, University of Amsterdam), Errica Barbazza (Academic Medical Centre, University of Amsterdam) and Frederico Guanais. Kees van Gool (University of Technology Sydney), Chunzhou Mu (University of Technology Sydney) and Jane Hall (University of Technology Sydney) carried out the statistical work underpinning the analysis of Chapter 3. Chapter 4 was written by Caroline Berchet and Frederico Guanais. Dionne Kringos (Academic Medical Centre, University of Amsterdam) and Erica Barbazza (Academic Medical Centre, University of Amsterdam) provided inputs to the policy analysis presented in Chapter 4. The preparation of Chapter 5 was a joint effort of a team of authors from the Bill & Melinda Gates Foundation (Hong Wang, Brienna Naughton, Ethan Wong, Nicholas Leydon, Caitlin Mazzilli, Susna De and Jean Kagubare) and the Ariadne Labs (Dan Schwarz, Amy VanderZanden and Asaf Bitton).
This report also benefited from the material received from Alexandre Barna and Hélène Colombani (the Fédération Nationale des Centres de Santé), Luc Besançon (pharmaSuisse), Erkkila Eila (Deputy Chief physician – City of Oulu), Mary McCarthy (European Union of General Practitioners) and Lukas Sekelsky (Ministry of Health of the Slovak Republic). The authors are also grateful to the Netherlands Institute for Health Services Research which provided access to the Quality and Costs of Primary Care (QUALICOPC) data, and in particular to Peter Spreeuwenberg for its research assistance. Neither they nor their institutions are responsible for any of the opinions expressed in this report.
At the OECD, Ian Forde, Michael Van den Berg and Niek Klazinga helped shape the overall direction of the report in an early phase. Nick Tomlinson, Francesca Colombo, Mark Pearson and Stefano Scarpetta provided valuable comments and suggestions at various stages of the project. Lukasz Lech, Duniya Dedeyn, Lauren Thwaites, Liv Gudmundson and Lucy Hulett provided vital support in the publication process. Thanks also go to José Bijholt, Frédéric Daniel, and Gabriel Di Paolantonio for their statistical support. The report was edited by Gemma Nellies.
Table of contents
Foreword
3
Acknowledgements
5
Acronyms and abbreviations
10
Executive summary
11
1 Key findings
14
1.1. Strengthening primary health care offers opportunities to make health systems more
efficient, effective and equitable 15
1.2. Primary health care is currently failing to deliver its full potential in many OECD countries 19 1.3. To strengthen primary health care in the 21st century it will be necessary to do things
differently 26
1.4. Conclusions: Summary of key policy ingredients to realise the full potential of primary
health care 44
References 49
Notes 59
2 Greater efficiency
60
2.1. Primary health care is associated with reduced use of costly hospital and emergency
department inputs 62
2.2. Shortcomings in primary health care delivery lead to unnecessary use of more expensive
specialised services 63
2.3. Policy options to enable the workforce to deliver more efficient primary health care 72
2.4. Conclusions 95
References 96
Notes 105
3 More effective and patient-centred care
106
3.1. Good quality primary health care improves health system responsiveness, makes health care more patient-centred and can improve health outcomes for the population 108 3.2. Disease prevention and care co-ordination are insufficient in a context of rising health care
needs 113
3.3. Policy options to encourage greater effectiveness and responsiveness 118
3.4. Conclusions 142
References 144
4 Less inequalities and more inclusive societies
153
4.1. Strong primary health care can improve the equity of health systems 155
4.2. Accessibility of primary health care services is a challenge in many OECD countries 158
4.3. Leveraging primary health care to reduce health inequalities 164
4.4. Conclusions 176
References 178
Notes 181
5 Primary health care in low- and middle-income countries
182
5.1. PHC Governance: Efforts should be stepped up to strengthen PHC governance in LMICs 184 5.2. Measurement of PHC: A more coordinated approach towards measurement of PHC is
needed in LMICs 187
5.3. Service Delivery Quality: Efforts must be strengthened to improve service delivery quality 191 5.4. Financing PHC: There are too many gaps in the current understanding of PHC financing in
LMICs 192
5.5. PHC Systems Design: Ensuring strong system design capacities for PHC 196
5.6. Conclusions 199
References 201
Notes 205
FIGURES
Figure 1.1. The share of generalist medical practitioners continues to drop across the majority of OECD
countries, 2000-17 20
Figure 1.2. Share of potentially avoidable hospital admissions due to five chronic conditions as a percentage
of total hospital bed days, 2016 22
Figure 1.3. Inappropriate use of antibiotics in general practice is high 23
Figure 1.4. One-quarter of patients suffering from chronic conditions in EU Countries did not receive any
preventive tests in the past 12 months, 2014 23
Figure 1.5. Involvement of primary health care practice in preventive activities has decreased by 13% over the
past two decades 24
Figure 1.6. Problems with care co-ordination between different health care professionals is common across
OECD countries, 2016 25
Figure 1.7. Prevalence of cervical cancer screening, by income quintile, 2014 (or more recent data) 26 Figure 1.8. Number of OECD countries using paying for prevention / co-ordination vs pay for performance
incentives 33
Figure 1.9. Eighteen OECD countries have implemented policy measures to collect nationwide performance
metrics to monitor the performance of primary health care 37
Figure 1.10. Less than half of OECD countries implemented concrete policy measures aimed at strengthening
the role of primary health care in protecting and improving workers’ health 42
Figure 2.1. Inappropriate use of antibiotics in general practice is high 64
Figure 2.2. The average volume of opioids prescribed in primary health care is more than 16 DDDs per 1 000
population per day, 2017 65
Figure 2.3. Opioid-related deaths in OECD countries have increased by an average of 20% in recent years 66 Figure 2.4. Share of potentially avoidable hospital admissions due to five chronic conditions as a percentage
of total hospital bed days, 2016 67
Figure 2.5. On average almost 30% of elderly patients visited an emergency department for a condition that
could have been treated in primary health care, 2017 69
Figure 2.6. The share of generalist medical practitioners continues to drop across the majority of OECD
countries 71
Figure 2.7. Strategies to develop the primary health care workforce have been implemented in 19 OECD
countries in the last five years 75
Figure 2.8. Seeking health information ranks second in the utilisation of digital technologies 81
Figure 2.10. Percentage of primary health care physician offices using electronic health records in OECD
countries, 2016 86
Figure 2.11. Number of OECD countries using paying for prevention/co-ordination vs pay for performance
incentives, 2018 90
Figure 3.1. Evolution and projection of obesity rates in selected OECD countries, 1990-2030 114 Figure 3.2. One-quarter of patients suffering from chronic conditions in EU countries did not receive any
preventive tests in the past 12 months, 2014 115
Figure 3.3. Involvement of primary health care practice in preventive activities has decreased by 13% on
average over the past two decades 116
Figure 3.4. Problems with care co-ordination between different health care professionals are common across
OECD countries, 2016 117
Figure 3.5. Basic information or test results from general practitioners not communicated to specialists, 2016 117 Figure 3.6. Bundled payments and population-based financing are not widely adopted across OECD countries 129 Figure 3.7. 18 OECD countries have implemented policy measures to collect nationwide performance metrics
to monitor the performance of primary health care 132
Figure 3.8. The percentage of people seeking health-related information online is increasing in all European
countries, 2008-17 138
Figure 4.1. The probability of a GP visit in the past 12 months differs by only 5 percentage points between the
lowest and highest income quintiles, 2014 (or more recent data) 157
Figure 4.2. In ten out of 33 countries, primary health care services are not affordable for more than 15% of the
population, 2013 159
Figure 4.3. Prevalence of cervical cancer screening, by income quintile, 2014 (or more recent data) 160 Figure 4.4. In many European and OECD countries, general practitioners are not available when patients
need them, 2013 161
Figure 4.5. The density of physicians is consistently greater in urban regions across OECD countries, 2016 (or
nearest year) 162
Figure 4.6. In many European and OECD countries, general practitioners are not easily reached by their
patients, 2013 163
Figure 4.7. In 20 OECD countries out of 32, patients receive free primary health care services at the point of
care 172
Figure 4.8. Less than half of OECD countries implemented concrete policy measures aimed at strengthening
the role of primary health care in protecting and improving workers’ health 174
TABLES
Table 1.1. New models of primary health care delivery have been established in 17 countries 35
Table 1.2. Summary of findings 44
Table 2.1. Cost of avoidable hospitalisation for chronic conditions in 30 OECD countries 68
Table 2.2. Involvement of nurses and assistants in health promotion and prevention 75
Table 2.3. Indicators used as part of the Estonian pay-for-performance programme 91
Table 3.1. Impact of primary health care spending on cervical and breast cancer screening uptake in the
OECD, 2005-15 111
Table 3.2. New models of primary health care delivery have been established in 17 countries 120
Acronyms and abbreviations
ACOs Accountable Care Organisations
ACSCs Ambulatory Care Sensitive Conditions
BMI Body Mass Index
CMS Centers for Medicare and Medicaid Services
COPD Chronic Obstructive Pulmonary Disease
CPCF Community Pharmacy Contractual Framework
CPRD Clinical Practice Research Datalink
CLI Combined Lifestyle Intervention
CPTS Communautés Professionnelles Territoriales de Santé
CCM Comprehensive Care Management
CPC Comprehensive Primary Care Initiative
CHF Congestive Heart Failure
DDD Defined Daily Dose
eHealth Electronic Health Systems
EHR Electronic Health Record
ePrescription Electronic Prescription
EU European Union
EBMeDS Evidence-Based Medicine electronic Decision Support
ENMR Expérimentations de Nouveaux Modes de Rémunération
GPs General Practitioners
IDB Inter-American Development Bank
LMICs Low- and Middle-Income Countries
mHealth Mobile Health applications
MMHUs Mobile Mental Health Units
MyHT My Health Team
NHS National Health Service
PHC Primary Health Care
PHCPI Primary Health Care Performance Initiative
PREMs Patient-Reported Experience Measures
PaRIS Patient-Reported Indicators Surveys
PROMs Patient-Reported Outcome Measures
P4P Pay-For-Performance
PIN Physician Integrated Framework
PHN Primary Health Network
QALICOPC Quality and Costs of Primary Care
QOF Quality and Outcome Framework
RPT Remote Presence Technology
ROSP Rémunération sur Objectifs de Santé Publique
SHOPS Sustaining Health Outcomes through the Private Sector
SDGs Sustainable Development Goals
UHC Universal Health Coverage
Executive summary
Primary health care can save lives and money while levelling the playing field to achieve more equal access to medical treatment. Such positive outcomes materialise when primary health care is a primary source of care that addresses the majority of their patients’ needs, knows their medical history, and helps them to co-ordinate care with other health services as needed. While in most OECD countries primary health care has not yet realised this full potential, several initiatives already show the way forward.
Based on the most promising country experiences, the OECD report Realising the Potential of Primary
Health Care finds that reconfiguring the delivery of primary health care with multi-professional teams,
equipped with digital technology, and seamlessly integrated with specialised care services, could help doctors, nurses, pharmacists and community health workers to provide more effective care. Empowering patients and measuring how primary care services deliver results that truly make a difference to their lives are also key for the provision of high performing care. If anything, the COVID-19 pandemic only makes these messages more relevant. Promising innovations in primary health care can boost the capacity of OECD health systems to contain and manage future health crisis and reduce unnecessary hospitalisation of people that can be effectively treated in the community. In other words, a modern and efficient primary health care system serves as the cornerstone of resilient health systems.
Strong primary health care makes health systems more effective, efficient, and
equitable
Interest in primary health care as a path for high performing health systems is not new. The 1978 Alma-Ata declaration recognised the critical importance of high-quality primary health care in the creation of effective and responsive health systems. Since then, the rising costs of medical care, increased citizen expectations from health systems, population ageing, and greater prevalence of chronic diseases have only reinforced the interest in the efficiency of primary health care.
With the share of the population aged 65 and above set to almost double to 28% by 2050, OECD countries must reconfigure their health systems to deliver more effective and high-quality care for people living for a long time with chronic conditions, while avoiding unnecessary use of hospital and specialised services. By providing the main point of contact for patients and especially for those with complex care needs, primary health care can make health systems more efficient, effective, and equitable across OECD countries.
Better, more accessible primary health care results in lower rates of hospitalisations and emergency department use. Primary health care can prevent unnecessary procedures and lower the need for the use of costly and scarce facilities, such as emergency rooms and hospitals.
Solid primary health care is also associated with lower health inequalities. Across the OECD and EU, 67% of people in the lowest-income group have seen a General Practitioner (GP) in the past 12 months relative to 72% in the top income bracket, a gap of 5 percentage points. Inequalities across income groups are significantly more pronounced when it comes to seeing a specialist (12 percentage points gap), or to have received breast cancer screening (13 percentage points gap). Primary health care can ensure access to vulnerable populations that otherwise can struggle to access medical services.
Most health systems are still failing to reach the full potential of primary health
care
So far, primary health care has not always been successful at keeping people out of hospitals. Across 30 OECD countries, hospitalisations for diabetes, asthma, chronic obstructive pulmonary disease, heart failures and hypertension alone – all of them largely avoidable through strong primary health care – correspond to 5.8% of all hospital bed-days. In 2016, these avoidable hospitalisations cost a total of USD 21.1 billion in this group of 30 countries.
Insufficient focus on prevention contributes to these results. Too many patients with chronic conditions still do not receive the recommended preventive care, especially the most vulnerable populations. One quarter of patients across 28 OECD and EU countries suffering with some chronic conditions did not receive any of the recommended preventive tests in the past 12 months.
In most countries, the share of doctors that work in general practice and the proportion of time general practitioners dedicate to preventive care is falling. On average, across OECD countries, generalists accounted for less than three out of ten physicians in 2017. In Australia, the United Kingdom, Denmark, Israel, Estonia and Ireland, the share of generalist medical practitioners decreased by more than 20% between 2000 and 2017.
Patients complain about a lack of communication and co-ordination between different parts of the health care system. In Norway, the United States, and Sweden more than 45% of patients experienced care co-ordination problems linked, for example, to test results, medical histories and receiving conflicting information, while in Germany it was just 29%.
New models of care, more economic incentives, and broader role to patients are
needed
Across OECD countries, promising innovations in primary health care are taking place, and the evidence base on how to promote greater effectiveness is growing. However, most of these experiences are at the local level or have small scale, and they have not yet achieved the full potential for a system-wide transformation of care. The report highlights the following necessary changes:
Second, more economic incentives are needed to encourage primary health care to work in teams and focus on prevention and continuity of care, especially for patients with chronic conditions, and close attention to care transitions co-ordination. Across OECD countries, policy innovations are taking place to provide better remuneration or economic incentives for the primary health care providers, based on their performance. In 2018, 11 OECD countries, including Israel, Mexico, and the United Kingdom, reported using specific add-on payments to incentivise care co-ordination, prevention activities or active management of chronic disease, and 15 countries, such as the Chile and Netherlands, reported using pay-for-performance mechanisms in primary health care.
Third, the future of primary health care increasingly depends on giving a broader role to patients. In part, this includes involving the patients in the co-production of their health, through better support to self-management of their conditions and exposure to risk factors. Digital tools can play a significant role in this context. In Canada and Finland, for example, patient-provider portals are used to improve communication with primary health care providers to provide patients with access to their own health data and to relevant, curated, health-related information. Listening to the patients through the regular collection of experiences and outcomes of care will be increasingly needed as a tool to improve what matters to them the most. The Patient-Reported Indicators Surveys (PaRIS) launched by the OECD in 2017 will address the need to understand the outcomes and experiences of people with chronic diseases.
These messages are as important as ever in the light of the COVID-19 pandemic which has, in many cases, accelerated the implementation of promising innovations in primary health care to achieve a system-wide transformation of care. Indeed, the coronavirus disease crisis has stimulated many innovative practices at national and local level, such as expanding the roles of nurses and pharmacists, developing digital solutions to monitor health status, ease access to care and using health information infrastructures for disease surveillance. Promoting the continuity of these practices and their wider adoption as health systems move into the pandemic recovery phase is critical for making health systems more resilient to health crisis.
This chapter provides an overview of the publication Realising the Potential
of Primary Health Care, as well as summarising the main findings. The
chapter starts by presenting the evidence base that associates strong
primary health care with more efficient, effective and equitable health care
systems. The second section shows that primary health care is currently
failing to deliver its full potential in many OECD countries, hampered by
avoidable hospital admissions, inappropriate antibiotic prescriptions,
insufficient preventive care or shortcomings in co-ordination. The third
section identifies policy levers to tackle these challenges, and provides an
overview of the report’s findings on how primary health care could provide
more efficient, effective and equitable care. The concluding section presents
a summary table of the key policy ingredients that countries will need to
address to realise the full potential of primary health care.
1.1. Strengthening primary health care offers opportunities to make health
systems more efficient, effective and equitable
In October 2018, health experts and policy makers met in Astana (Kazakhstan) to celebrate the 40th anniversary of the Alma-Ata declaration which recognised the critical importance of quality primary health care in the creation of effective and responsive health systems (see Box 1.1).
The increased recognition of the primacy of strong primary health care is not new: strengthened primary health care systems have the potential to improve health outcomes across socio-economic levels, to make health systems more people-centred, and to improve health system efficiency in the 21st century. This is ever more needed, particularly in OECD countries, where citizen expectations of services are high, societies are ageing, complex cases are costly, and fiscal pressures make it difficult to expand overall allocation of resources to the health sector. The critical role of primary health care has become even clearer during the COVID-19 pandemic. As countries sought to cope with the surge in demand for patients acutely ill with a new, highly infectious disease, while needing to maintain care for chronic patients under difficult circumstances, this pandemic has stimulated many innovative practices at national and local level. Such innovations can be captured with a view to promoting their wider adoption as health systems adapt as they move into the pandemic recovery phase and beyond.
Across the OECD, citizen expectations are high, and a considerable share of the population believe better health services are needed. On average, across the 21 OECD countries surveyed, just over half of the population believe that becoming ill or disabled is one of the top-three social or economic risks facing them or their immediate family in the near future, and in 14 out of 21 countries, this was their top concern. Moreover, 48% of the population identified health care as one of the three top areas requiring additional support from the government to make them and their family feel more economically secure (OECD, 2019[1]).
In addition, populations are ageing and health needs are becoming more complex. The share of the population aged 65 years and over is expected to grow by more than 60% across OECD countries, rising from 17% in 2017 to 28% by 2050. Up to 40% of people in OECD countries live with multi-morbidities, with up to 25% of people suffering from three or more chronic diseases (OECD, 2019[2]). In addition, 20% of the adult population in EU countries is affected by chronic pain (PAE - Pain Alliance Europe, 2018[3]), and around 17% of people in Europe have a mental health problem, such as anxiety or depressive disorders (OECD/EU, 2018[4]). Multiple layers of health problems can accumulate in some people, who form the relatively small group of more complex patients, accounting for a disproportionally large share of health care costs. A recent systematic review found that the top 10%, 5%, and 1% of high-cost patients account for 68%, 55% and 24% of costs respectively within a given year (Wammes, van der Wees and Tanke, 2018[5]).
While needs are on the rise, fiscal space for growth in resources is limited. Many countries have already allowed health to take a larger share of their budgets over time, with health spending now averaging 15% of government spending in OECD countries (Lorenzoni et al., 2019[6]). Increased health spending in the past has been offset by lower public spending in other areas, such as defence and other public services. Continuing such reallocations to health in the future may be increasingly difficult in the face of competing demands for government resources.
Box 1.1. The Astana declaration
In October 2018, health experts and policy makers met in Astana (Kazakhstan) to renew the commitment to comprehensive primary health care for all. The new Astana declaration reaffirms the commitment to the Alma-Ata core principles.
The new Declaration envisions “primary care and health services that are high quality, safe, comprehensive, integrated, accessible, available and affordable for everyone and everywhere, provided with compassion, respect and dignity by health professionals who are well-trained, skilled, motivated and committed”. Priority is explicitly given to promotive, preventive, curative, rehabilitative and palliative care; and to the increasing importance of non-communicable diseases which lead to poor health and premature deaths, and to environmental factors such as natural disaster, climate change or other extreme weather events.
Source: Declaration of Astana – Global Conference on Primary Health Care (2018[7]), https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf; Hirschhorn et al., (2019[8]), “What kind of evidence do we need to strengthen primary healthcare in the 21st century?”, https://doi.org/10.1136/bmjgh-2019-001668.
Box 1.2. What is primary health care?
Primary health care is expected to be the first and main point of contact for most people with the health care system, focused on the people and their communities. It takes into account the whole person and is patient-focused, as opposed to disease or organ system-focused, and thus recognises not only physical, but also psychological and social dimensions of health and well-being. The most commonly used definitions of primary health care encompass the following characteristics:
People and community orientated – primary health care operates in close proximity with
where people live or work, and provides care that is focused on the needs of local people and their families.
Continuous care – primary health care is the first point of contact with the health system, and
the people who use it identify it as their main source of care over time.
Comprehensive – primary health care addresses the majority of health problems of the people
it serves, providing preventive, curative and rehabilitative services.
Co-ordinated – primary health care helps patients navigate the health system, communicating
effectively with the other levels of care. It goes beyond services provided solely by primary health care physicians and encompasses other health professionals such as nurses, pharmacists, auxiliaries and community health workers.
1.1.1. Strong primary health care can reduce unnecessary use of more expensive health
care resources and improve health system efficiency
There is strong evidence that associates better, more accessible primary health care with lower rates of hospitalisations(Wolters, Braspenning and Wensing, 2017[10]; Rosano et al., 2013[11]; van Loenen et al., 2014[12]) and emergency department use (Huntley et al., 2014[13]; Kirkland, Soleimani and Newton, 2018[14]; Berchet, 2015[15]). Primary health care can avoid unnecessary procedures and lower the need for the use of costly and scarce facilities, such as emergency rooms and hospitals, which contributes to better spending and improving health system efficiency.
The conditions for which primary health care can generally prevent the need for hospitalisation, or for which early intervention can reduce the risk of complications, or prevent a more severe disease from developing are ambulatory care sensitive conditions (ACSCs) (Agency for Healthcare Research and Quality, 2018[16]). Diabetes, chronic obstructive pulmonary disease (COPD), asthma, hypertension and congestive heart failure (CHF) are all ACSCs with an established evidence base that much of the treatment can be delivered by outpatient care at the primary or community care level. Treated early and appropriately, acute deterioration in people with these conditions and consequent hospital admissions could largely be avoided, therefore hospitalisations due to ACSCs are defined as “avoidable hospitalisations” (Purdy, 2010[17]; Nuffieldtrust, 2019[18]) (Starfield, Shi and Macinko, 2005[19]).
In addition to generating avoidable hospitalisations, delays in diagnosis and inappropriate therapeutic interventions in primary health care for these ACSCs are also key sources of patient harm, and can result in emergency department visits(Lin, Wu and Huang, 2015[20]; Sung, Choi and Lee, 2018[21]; Van den Berg, Van Loenen and Westert, 2016[22]; van Loenen et al., 2014[12]). Such emergency department visits are considered “inappropriate” or non-urgent visits, and are characterised by low urgency problems which could be better addressed by other health services than emergency admission including, for example, telephone-based services and primary or community health care services (McHale et al., 2013[23]). According to national definitions and estimates, “avoidable”, “inappropriate” or “non-urgent” visits to emergency departments account for nearly 9% of emergency department in Australia (Aihw, 2018[24]), 12% in the United States, between 11.7% and 15% in England, 20% in Italy, 25% in Canada, 31% in Portugal and 56% in Belgium (Berchet, 2015[15]).
As unit costs for treating patients with the same condition in primary health care are lower than those observed in emergency rooms and hospitals, health systems with strong primary health care may attain higher levels of allocative efficiency, which describes a situation where a different combination of inputs could bring better results. Therefore ACSCs are indicators of possible misallocation of resources across different types of goods and services or, in this case levels of care, when comparing primary health care with the alternatives of emergency rooms or hospitals (Cylus, Papanicolas and Smith, 2016[25]).
1.1.2. Strong primary health care can improve population health outcomes and health
system responsiveness
More recently, several other studies have shown that countries with strong primary health care performed better on other major aspects of health, including outcomes for patients with chronic diseases. Kringos et. al. (2013[28]), for example, found that both the structure of primary health care (as measured by the governance, economic conditions and workforce development in the primary health care sector) and the co-ordination and comprehensiveness of primary health care were positively associated with the health of people with ischemic heart diseases, cerebrovascular diseases and other chronic conditions including asthma, bronchitis and emphysema. In addition, there is strong evidence that primary health care interventions have a positive impact on measures of mental health indicators, including depression and anxiety (Conejo-Cerón et al., 2017[29]; Trivedi, 2017[30]).
The main positive effect of good primary health care on health outcomes draws from the role it plays in supporting and facilitating the uptake of preventive activities (primary, secondary and tertiary prevention). Primary health care is well placed to carry out preventive interventions not related to any specific disease or organ system. In particular, this hypothesis has been supported in empirical work specific to:
health counselling regarding smoking cessation (Shi and Starfield, 2005[31]; Saver, 2002[32]) immunisation (Sans-Corrales et al., 2006[33]; Hartley, 2002[34])
early detection of breast cancer, colon cancer and melanoma (Campbell et al., 2003[35]).
In addition to better population outcomes, there is evidence that strong primary health care also improves health system responsiveness and makes systems more patient-centred. For example, a study that included 12 OECD countries and 5 other countries in Latin America and the Caribbean found that, on average, patients who had a regular place of care, where there was familiarity with their medical history, where it was easy to communicate with the primary health care team, and where that team helped to co-ordinate care, were 12.1% less likely to say that their health system needs major changes and 29.2% more likely to perceive their usual provider as offering high quality care (controlling for health needs and overall health system characteristics) (Guanais et al., 2019[36]). Moreover, patients who had a physician who explained things in a way that was easy to understand and who spent enough time with them during consultations were 8.6% less likely to say that their health system needs major changes and 69.6% more likely to perceive their usual provider as offering high quality care.
Very recently, Levine, Landon and Linder (2019) have shown that primary health care can offer high value, responsive and patient-centred care. Compared to adults without primary health care, adults with primary health care were more likely to have routine preventive care, to receive high value-care (such as high-value cancer screening, recommended diagnostic and preventive testing, and high-high-value counselling), and to report better experience with care delivery (Levine, Landon and Linder, 2019[37]).
1.1.3. Strong primary health care can improve the equity of health systems
Primary health care has been described as well placed to support health equity for a number of reasons (Chetty et al., 2016[38]). By definition, it has a broader population coverage than any specialty, therefore it has a better platform for accessing a large number of people. It has direct contact with patients, and most patients will see their primary health care physician as the first point of contact with the health service. In 14 out of the 36 OECD countries that responded to the 2016 OECD Health System Characteristics Survey, patients are obliged to register with a primary health care physician.
than a person with high income to see a specialist (OECD, 2019[39]). Systematic reviews of published literature confirm the evidence base that associates strong primary health care and lower health inequalities(Kringos et al., 2010[40]; Salmi et al., 2017[41]).
Evidence also suggests that continuous and comprehensive care provided by the primary health care team can provide effective health education and prevention interventions based on the medical and social needs of the patients (Ruano, Furler and Shi, 2015[42]; Chetty et al., 2016[38]). This helps tackle risk factors and other social determinants of health, which in turn improves equity of health outcomes. In England, for example, strengthening primary health care in underserved areas, notably through the implementation of effective interventions for secondary prevention of cardio-vascular heart disease, diabetes and other chronic conditions, has helped to reduce the absolute socio-economic gaps in mortality amenable to health care from 2007 to 2011 (Cookson et al., 2017[43]).
1.2. Primary health care is currently failing to deliver its full potential in many
OECD countries
Despite evidence demonstrating the contribution of primary health care to health systems in terms of improvements in health outcomes, efficiency, and people-centred care, primary health care is not achieving the expected results in many OECD countries. This section presents examples of shortcomings in primary health care performance in terms of:
poor efficiency, as shown by high levels of avoidable hospitalisations and excessive prescriptions
of antibiotics
ineffective and low responsiveness, as indicated by low overall utilisation of recommended
preventive care, and problems of co-ordination of care between primary health care, specialists, and hospitals
inequitable, as evidenced by inequalities in access to screening tests across different income
levels.
These international figures show that primary health care systems are not operating as effectively as they should, whether in terms of keeping people healthy, preventing costly hospitalisations, meeting peoples’ expectations or ensuring equal access to quality health services. These shortcomings may partly relate to a shortage and mismatch of skills in primary health care practice, which leads to sub-optimal use of resources in primary health care.
1.2.1. Workforce pressures in primary health care are high
Reductions in the share of generalist medical practitioners and new burdens in workload are
putting strain on primary health care teams
Figure 1.1. The share of generalist medical practitioners continues to drop across the majority of
OECD countries, 2000-17
% changes between 2000 and 2017
Note: The category of generalist medical practitioners includes general practitioners, district medical doctors, family medical practitioners, primary health care physicians, general medical doctors, general medical officers, medical interns or residents specialising in general practice or without any area of specialisation yet. Generalist medical practitioners do not limit their practice to certain disease categories or methods of treatment, and may assume responsibility for the provision of continuing and comprehensive medical care to individuals, families and communities. There are many breaks in the series for Australia, Estonia, and Ireland over the period. In some countries (Ireland, Israel, Korea and Poland), the share of general practitioners among all doctors has increased over the same period.
Source: OECD Health Statistics 2019, https://doi.org/10.1787/health-data-en.
The reduction in the share of generalist medical practitioners is coupled with an upward trend in both the clinical and administrative workload of general practice. This is observed across several OECD countries, including the United Kingdom (Hobbs et al., 2016[44]; Thompson and Walter, 2016[45]), Australia (The Royal Australian College of General Practitioners, 2018[46]), and Canada.(Grava-Gubins, Safarov and Eriksson, 2012[47]; Medical Association, 2017[48]). In a similar vein, the current workload for primary health care physicians was found to be unreasonable and unsustainable over the longer term in 14 European Countries (Croatia, Hungary, Ireland, Lithuania, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovenia, Spain, Sweden, Turkey)1. This growing workload might adversely affect the quality of patient care, and is inadequate to meet patients’ needs (Fisher et al., 2017[49]).
The current distribution of skills and tasks among primary health care teams is inefficient
Across OECD countries, there is a mismatch of skills and tasks within primary health care teams to population and patient needs (Frenk et al., 2010[50]; OECD, 2016[51]). Previous estimations show that more than three-quarters of doctors and nurses reported being overskilled for some of the tasks they have to do in their day-to-day work. Nurses having a master’s level or equivalent are, for example, twice as likely to report being overskilled for some of the work they do than those qualified up to bachelor’s degree level. The mismatch of skills and tasks represents a dramatic waste in human capital given the significant length
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Estonia Denmark
United KingdomAustralia
Chile
NorwayPoland
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Czech RepublicKorea
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Mexico NetherlandsOECD32 Spain Turkey Canada Luxembourg
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of training of doctors and nurses. In the United Kingdom, up to 77% of preventive care and 47% of chronic care could be delegated to non-physician team members (Shipman and Sinsky, 2013[52]), while in the United States the amount of administrative work doctors have to do is increasing. For example, for every hour physicians were seeing patients, they were spending nearly two additional hours on administrative work (including electronic health records [EHRs] and deskwork) (Sinsky et al., 2016[53]). Many primary health care systems aim to improve care co-ordination and it may be that the increase in paperwork and other administrative tasks relates to these increased responsibilities. This is not a bad thing per se, but such non-medical tasks should be delegated to appropriate staff, thereby reducing administrative workload for medical staff and improving time for patient care and communication.
At the same time as being overskilled for some tasks, physicians and nurses also report being underskilled for others. Across OECD countries, 51% of doctors and 43% of nurses reported being underskilled for some of the tasks they have to do. A systematic review found that, on average, clinicians have more than one question about patient care for every two patients (regarding drug treatment, symptoms or diagnostic results), and nearly half of these questions are not pursued (Del Fiol, Workman and Gorman, 2014[54]). Further, primary health care teams might not have important soft skills to deliver people-centred care, such as shared communication, collaboration and partnership (Ranjan, Kumari and Chakrawarty, 2015[55]). Primary health care teams seem ill-prepared to meet growing and complex health care needs given technological progress, new ways of delivering services and the rapid pace of medical knowledge development. The need for change in the training and development of primary health care teams is thereby evident.
1.2.2. There are several shortcomings in primary health care performance across OECD
countries
Avoidable hospitalisations for chronic conditions remain high
Avoidable hospitalisations are a prime example of inefficient use of resources at the health system level, and this indicator has been used for years across OECD countries (Auraaen, Slawomirski and Klazinga, 2018[56]). Analysis of hospital admission data for five chronic conditions (diabetes mellitus, hypertensive diseases, heart failure, COPD and asthma) across OECD countries for which data were available, shows that in 2016, just over 5.6 million hospitalisations with a principal diagnosis of one of these five conditions took place (see Chapter 2 for methodology). This suggests that primary health care is not always successful at keeping people out of hospitals. In total, in 2016, over 47.5 million bed days were consumed by admissions for these five chronic conditions alone across OECD countries, amounting to 5.8% of the total hospital bed day capacity (Figure 1.2).
Using the 2011 WHO CHOICE model, which estimates the “cost per hospital bed day”, it is possible to give a rough estimation of the opportunity cost associated with avoidable hospitalisation for ACSCs across OECD countries. Only the “hotel” component of hospital costs (including costs such as personnel, capital and food costs) is considered here, excluding the cost of drugs, treatment and diagnostic tests. This means that the opportunity cost related to avoidable hospitalisations for these five chronic conditions is largely underestimated. Moreover, several countries have developed lists of causes of hospitalisation that are potentially avoidable, including more conditions than the five listed in this estimation (for example angina, influenza and other vaccine preventable diseases, illnesses resulting from nutritional deficiencies, etc.) (Fleetcroft et al., 2018[57]). Therefore, the total number of avoidable hospitalisations is also significantly underestimated.
Figure 1.2. Share of potentially avoidable hospital admissions due to five chronic conditions as a
percentage of total hospital bed days, 2016
Note: The data includes only admissions with a minimum of one night’s hospital stay. Not counted are ‘same-day’ admissions (e.g. a patient with acute on chronic conditions admitted for observation but discharged a few hours later). These “same-day” admissions consume hospital resources. In addition, the share of avoidable hospital admissions is also largely underestimated as there are more causes of hospitalisations that are potentially preventable. In Australia for example, potentially avoidable hospitalisations for 22 conditions accounted for 9% of all hospital bed days in 2016-17 (AIHW, 2019[58]). Cross-country comparisons of potentially avoidable hospital admissions should also be interpreted with caution, as many other factors, beyond better access to primary health care, can influence the statistics, including data comparability and the prevalence of these chronic conditions. These are crude data and are not age-standardised.
Source: OECD estimates based on OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.
Inappropriate prescribing, such as for antibiotics, is excessive in general practice
Appropriate prescribing is a good marker of primary health care quality, but also of allocative efficiency, because it indicates inappropriate use of resources. One example is the appropriate use of antibiotics in primary health care. Antibiotics should be used only when there is evidence that they are needed to address infections. However, recent evidence shows that general practice services are an area of concern, as consistently high levels of inappropriate use are reported. The inappropriate use of antibiotics in general practice ranges between 45% and 90% (Figure 1.3). The volume of all antibiotics prescribed in primary health care in 2017 was 19 defined daily doses per 1 000 inhabitants per day across OECD countries, but ranged from 10 in Estonia and Sweden to 36 in Greece (OECD, 2019[59]).
Too many patients with chronic conditions still do not receive the recommended preventive
care
Insufficient preventive care throughout the course of life increases the probability that old age will be marked by health problems and disabilities. This has the potential to create future financial liabilities for health systems, particularly in OECD countries, since societies are ageing and the burden of chronic disease is growing. 0% 2% 4% 6% 8% 10% 12%
Figure 1.3. Inappropriate use of antibiotics in general practice is high
Note: Numbers in brackets indicate the number of studies used to determine the range of inappropriate use. Source: OECD (2017[60]), Tackling Wasteful Spending on Health, https://doi.org/10.1787/9789264266414-en.
As the first point of contact with the health care system, and as a trusted source of information, primary health care teams are in a unique position to advise patients on healthy lifestyles and behaviour, to administer screening tests, and to manage and control the progress of chronic conditions. However, recent data shows that too many patients with chronic conditions do not receive the recommended preventive care. In 2014, across EU countries, 26% of patients suffering from certain chronic conditions did not receive any of the recommended preventive tests in the previous 12 months (Figure 1.4). This proportion reaches nearly 50% in Iceland, followed by Finland, Norway, Sweden, Romania, and Slovenia, where more than a third of people with chronic conditions did not receive the recommended tests in the previous 12 months. At the lower end of the scale, in Spain, Belgium, the Czech Republic, Luxembourg and Portugal, less than 20% of people with chronic conditions did not receive the recommended tests in the previous 12 months.
Figure 1.4. One-quarter of patients suffering from chronic conditions in EU Countries did not
receive any preventive tests in the past 12 months, 2014
Note: The data refer to the proportion of people suffering from hypertension, myocardial infarction (or chronic consequences of myocardial infarction), stroke (or chronic consequences of stroke) or diabetes, who did not receive any blood pressure measurement, blood sugar measurement or blood cholesterol measurement in the previous 12 months. Data corresponds to the year 2014, in which the United Kingdom was member of the European Union and therefore part of the EU average.
Source: OECD estimates based on EHIS-2. 0 10 20 30 40 50 60 70 80 90 100
Dialysis [3] Paediatric [9] Critical care [5] Ambulatory [4] Hospital/tertiary [27]Long-term care [13] General practice [4]
Figure 1.5. Involvement of primary health care practice in preventive activities has decreased by
13% over the past two decades
% relative change in disease treatment (
) and in prevention (
) between 1993 and 2012
Note: Involvement in prevention includes the measurement of blood pressure, the measurement of cholesterol, and providing health education. Source: Adapted from Schafer et. al., (2016[61]), “Two decades of change in European general practice service profiles: Conditions associated with the developments in 28 countries between 1993 and 2012”, https://doi.org/10.3109/02813432.2015.1132887.
Previous work suggests a decrease in preventive care by primary health care teams (Figure 1.5) (Schäfer et al., 2016[61]). Involvement of primary health care practice in curative care has increased all over Europe over the past decade, while involvement in preventive activities has decreased by 13%, on average, over the same period (Schäfer et al., 2016[61]). Italy, Poland, Finland, Portugal, Romania, Iceland, Denmark and Hungary saw the most significant decreases of more than 50% (Figure 1.5). By contrast, the increase in primary health care practice involvement in treatment of disease is particularly marked in Turkey (+32%), Romania (+26.7%) and Slovenia (+25.2%). Increased participation in treatment may be one of the reasons why preventive care is not being delivered properly.
Patients report significant co-ordination problems between primary health care, specialists
and hospitals
Integration and co-ordination of care correspond to an important dimension of patient-centred care (Santana et al., 2019[62]). This requires a good flow of information and consistency of decisions across the different levels of care in the health system, including primary health care settings, specialist settings and hospitals. When care is not co-ordinated, patients have to repeat information or diagnostic tests, conflicting instructions are given, and transitions between providers – for example at hospital discharge when patients are referred back to primary health care – may be associated with adverse effects (Couturier, Carrat and Hejblum, 2016[63]).
Evidence from patient-reported data indicates that there are high levels of care co-ordination problems between primary health care, specialists and hospitals. Figure 1.6 shows that between 29% and 51% of the people surveyed in 11 OECD countries in 2016, reported having experienced problems of care co-ordination. These co-ordination problems refer to: medical tests not being available at the time of appointment or that duplicate tests were made; specialist did not have basic information from GP or GP not informed about specialist care; or received conflicting information from different providers.
Figure 1.6. Problems with care co-ordination between different health care professionals is
common across OECD countries, 2016
Note: Care co-ordination problem is defined as: test results/records not being available at appointment or duplicate tests ordered; specialist lacked medical history or regular doctor not informed about specialist care; and/or received conflicting information from different doctors or health care professionals in the past two years. The Swedish response rate in the Commonwealth Fund International Health Policy Survey is low, so cross-country comparability is low. The proportions are controlled for age, gender and health status.
Source: Commonwealth Fund International Health Policy Survey 2016.
People with lower incomes have a lower probability of undergoing screening
Despite fairly low inequalities in access to a GP, people with a lower income consistently have lower utilisation rates of preventive services in virtually all EU and OECD countries (OECD, 2019[39]). This indicates that primary health care may not be succeeding in delivering recommended preventive care across different socio-economic levels.
For cervical, breast and colorectal cancers, the probability that those in the target population and in the lowest-income quintile will have undergone screening in the recommended period are significantly lower than that of people in the highest-income quintile. For instance, only 61% of women with a low income had cervical cancer screening, compared to 78% of women with high income. Figure 1.7 presents the rate of cervical cancer screening, showing large income-related inequalities in screening uptake in many EU and OECD countries. 29 34 35 36 38 40 42 43 47 47 51 0 10 20 30 40 50 60
Germany Australia New Zealand France United
Kingdom Canada Netherlands Switzerland Norway United States Sweden
Figure 1.7. Prevalence of cervical cancer screening, by income quintile, 2014 (or more recent data)
Share of women aged 20-69 years who had a pap smear test in the past 3 years in 32 European and OECD countries
Note: Small sample size in Bulgaria (about 300 individuals per income group for this analysis). Screening rates in the Netherlands are higher based on national surveys.
Source: OECD (2019[39]), Health for Everyone?: Social Inequalities in Health and Health Systems, https://dx.doi.org/10.1787/3c8385d0-en.
1.3. To strengthen primary health care in the 21st century it will be necessary to
do things differently
There are many contributing factors that can help explain why primary health care is not delivering to its full potential.
In part, it may be linked to the fact that primary health care physicians are not doing the right things, for example, not doing enough preventive medicine, or not co-ordinating care to help avoid hospitalisation or unnecessary complications. Several countries have sought to encourage improved allocative efficiency of primary health care tasks through, for example, different payment schemes and non-financial incentives, or an improved matching of doctors’ skills to tasks.
Another reason could be the lack of resources in primary health care relative to other sectors. More Czech Republic Austria Luxembourg France Germany Sweden United States Iceland Finland Latvia Slovenia Croatia Canada Greece Belgium Chile Poland Portugal Hungary Average Spain Ireland Slovak Republic Italy Norway Cyprus Denmark Malta United Kingdom Lithuania Estonia Bulgaria Netherlands Romania Lowest income quintile Average Highest income quintile 0 10 20 30 40 50 60 70 80 90 100
way to improve the delivery of health care output. However, the declining share of GPs, due in part to the lower attractiveness of general practice relative to specialist care, mean that fewer primary health care physicians are asked to deliver care to a growing number of people with complex care needs. A number of countries have sought to counter the increasing trends towards specialisation through training and task delegation.
A third reason, could be that the organisational model of primary health care still mostly relies on face-to-face consultations with a physician who works in a solo practice. Better use of teamwork, inclusion of other health professionals and electronic communication could potentially increase the pool of patients that every primary health care physician oversees, while effectively improving the quality of services provided (Green, Savin and Lu, 2013[64]). Moreover, better integration of health and social care services could offer opportunities to better address social determinants of health and reduce the need for health care services. Overcoming these problems will require new models for the delivery of primary health care, extensive use of digital tools and financing mechanisms that reward performance. This section discusses policy levers that can be used by OECD countries, in the 21st century, to improve the efficiency, effectiveness, responsiveness and equity of their health systems, through more effective and stronger primary health care.
1.3.1. Improving the efficiency of primary health care
New mechanisms for workforce recruitment and training are needed to improve allocative
and technical efficiency
Changes in training are more important than ever, given the challenges and opportunities introduced by digital technologies and new ways of delivering services
With technological progress and new ways of delivering services, primary health care systems are changing rapidly. Professional education in primary health care may not be aligned with these changes, and may not match increasing citizen expectations and rising health care needs. As illustrated by Schafer et al (2016[61]), primary health care practices do not engage sufficiently in preventive care and mostly deliver care that focuses on disease treatment, often targeting one illness at a time (Schäfer et al., 2016[61]) (see also Chapter 3). Such an approach is not appropriate in today’s climate and changes are needed to realise the required efficiency gains.
To improve technical efficiency, the primary health care team needs to have expertise on a wide range of areas, which go beyond treating infectious diseases, and include: nutrition, addiction, mental health and healthy ageing. Consistent with a people-centred approach, “soft” and transversal skills are also needed when engaging in prevention and disease management activities, such as behaviour counselling, shared communication, collaboration and partnership (Ranjan, Kumari and Chakrawarty, 2015[55]).
Providing initial and continuing training programmes in all these areas is critical in providing the tools and knowledge that allow primary health care teams to engage in these activities properly. Initial and continuing education should prepare primary health care teams to:
Manage and control chronic diseases and associated risk factors. Screening assessment tools, individual counselling, and behavioural change programmes should be the main priority of training programmes in primary health care, at least to the same extent as diagnosis and treatment of diseases.
Use technological resources effectively. Primary health care teams need to learn how to use digital tools, such as technology-enabled consultation, clinical data coding and IT-based quality improvement.
Achieve skills for person-centred communication. It is vital to expand attention to patients’ personal and social situations in order to improve diagnosis and tailor care plans, and to practice shared decision making to address patients’ goals and values.
Achieve skills for effective teamwork and interprofessional collaboration, notably to break down professional silos and enable effective working both with, and through other health and social care professionals.
Several health care systems are working toward these goals. For example, to strengthen providers’ competencies in IT-based quality improvement tools, England has developed the NHS Digital Academy. In a similar vein, Canada, Germany and the United States have introduced modules in the medical curricula to ensure health care professionals achieve skills for data-driven quality development, digital literacy and interprofessional collaboration. In France, the Ministry of Health, jointly with the Ministry of Education, recently announced that the primary health care workforce will have to perform a public health rotation (see Box 1.3).
Box 1.3. The public health rotation in France
The Ministry of Health, jointly with the Ministry of Education, recently announced that students in the health field will have to perform a public health rotation (called “service sanitaire”). The new curricula for medical doctor, nurse, pharmacist and physiotherapist students consists of going to public places, such as universities and high schools, to undertake prevention activities on four priority areas: diet, physical activity, addictions, and sexual health (see also Box 2.2). It is estimated that from 2019 around 50 000 students per year will undertake the public health rotation.
Source: OECD (2018[65]), Policy Survey on the Future of Primary Care.
The efficiency of primary health care in the future will also depend on the use of community-based teams
New support role for nurses, community pharmacists and community health agents have the potential to reduce the workload of primary health care physicians, without undermining the quality of care and patient satisfaction (Green, Savin and Lu, 2013[64]). Ensuring that the primary health care workforce has sufficient professionals with the right mix of skills will be key to making sure new models of primary health care delivery meet local health needs. Nurses, community pharmacists and community health agents frequently have all-important soft skills and relevant knowledge about their communities. OECD health care systems need to harness the full capacity of these community-based teams by setting up appropriate training and ensuring that legislation is adequate, whilst not being unnecessarily restrictive.
However, the majority of nurses or assistants independently provided immunisation, health promotion or routine checks for chronically ill patients in less than half of OECD countries in 2016 (OECD, 2016[66]), and only 19 OECD countries (OECD, 2018[65]) reported strategies to develop the primary health care workforce (see Chapter 2).
